Code Stroke Intervention: Endovascular Therapies for Stroke J. DIEGO LOZANO MD INTERVENTIONAL NEURORADIOLOGY

Disclosures None

Part A. Objectives Epidemiology of AIS and of ELVO Concept: Acute Ischemic Stroke Emergent Large Vessel Occlusion (AIS-ELVO) Know about NIH Stroke Scale and modified Rankin Scale Update on guidelines and current medical and endovascular management of AIS-ELVO Who to treat? When to treat? Cases Management from RN perspective, before and after endovascular therapy

Acute Ischemic Stroke Someone in the US has a stroke about once every 40 seconds. ~ 795,000 new or recurrent strokes each year 610,000 are first attacks 5th leading cause of death in US #1 cause of adult disability *AHA Stroke Facts, 2017

ACUTE ISCHEMIC STROKE Risk factors Prior TIA or stroke DM Family history of atherosclerosis CAD PAD aka PVD Atrial fibrillation CHF Dilated cardiomyopathy HTN Lack of physical activity Metabolic syndrome Advanced age Overweight/Obesity Smoking HLD High LDL, low HDL Sickle cell disease

ELVO-A New Era LVO-Prelude to a New Era Emergent Public awareness Stroke systems of care LVO (Large Vessel Occlusion) Device/technique maturation Appropriate patient selection Proof of benefit

ELVO Stroke-Time is Brain 1.8 million neurons lost each minute Probability of a good outcome reduced 10% every 30 minutes until treated *Stroke 2006; 37: 263 266

AIS-ELVO a Team Effort Community Education EMS appropriate triage to CSC Rapid ED evaluation and triage to endovascular Acute Neurology/ Neuro IR Endovascular specialty consultation t-pa and/or Embolectomy Neurocritical care Rehabilitation Risk factor modification

AIS-ELVO Severe trauma STEMI ELVO Advanced trauma care Level I Trauma Ctr. Cath Lab PCI Facility Endovasc. Tx. Comprehensive Stroke Ctr. Evidence based Evidence based Evidence based

Acute ischemic stroke Emergent Large Vessel Occlusion (AIS-ELVO) 101

What do we consider a Large Vessel ANTERIOR CIRCULATION Occlusion amenable to thrombectomy? Acute blockage of a proximal great vessel Internal carotid artery cervical and/or intracranial Proximal Middle Cerebral Artery (MCA) M1 segment M2 segment POSTERIOR CIRCULATION Acute blockage of a proximal great vessel Vertebro basilar / Basilar trunk Posterior cerebral artery (PCA) P1 segment/p2 segment M3 segment (?) Proximal Anterior Cerebral Artery (ACA) A1 segment A2 segment

ELVO Stroke-Clinical Small Vessel Stroke Weakness (Common face=arm=leg) Sensory less common Dysarthria (slurred speech) common No cortical signs Large Vessel Stroke Weakness (Common face=arm>leg) Sensory common CORTICAL signs Aphasia Gaze preference Visual field cut Neglect/Agnosia

Code Stroke Code Stroke Intervention Code Stroke HOB flat unless contraindicated Determine time of symptom onset or last known well Determine neurological deficits / Determine mrs Continuous monitoring of vital signs HR, BP, pulse oximetry Draw labs. 20 G i.v access (ideally x 2), forearm or above Avoid placing i.v. in dorsum of hand CT/CTA Consult Neurology / Neurointerventionalist i.v TPA if eligible Code Stroke Intervention if ELVO and eligible

26 y.o. Female acute onset of weakness and difficulty speaking. Last known well 1 hour prior to admission

Diagnosis? Which side is the vessel occluded? Right or left? Which vessel is likely occluded? A. Left Internal Carotid Artery (ICA)? B. Left middle cerebral artery (MCA)? C. Left anterior cerebral artery (ACA)? D. Left posterior cerebral artery (PCA)? E. Basilar artery?

ELVO Stroke-Time IV thrombolysis with t-pa 3-4.5 hours Level IA evidence based IV window Thrombectomy studies: treated within 6 hours Level IA evidence-based IA window Thrombectomy devices are FDA-approved up to 8 hours (Anterior circulation) Trevo, Penumbra, Solitaire, other experimental devices Some patients may benefit beyond 6-8 hours Area of active research interest DAWN study Thrombectomy in up to 24 hours of last known well http://blog.gembaacademy.com/2008/06/30/ban-the-stop-watch/

Stroke Trials: Outcome from 5 RCTs

AHA/ASA Guidelines 2015 AH/ASA focused update of the 2013 guidelines for the Early Management of Patients with AIS regarding endovascular treatment Class I, LOE A: Endovascular Therapy Pts should receive IAT if they: Have baseline mrs < 1, received i.v. r-tpa, ICA or M1 occlusion > 18 y/o NIHSS > 6 ASPECTS > 6 Start treatment within 6 hrs (LOE A, new) If considering IAT, vessel imaging recommended but should not delay IV r-tpa (LOE A, new)

AHA/ASA Guidelines Class IIB; LOE C Treatment initiated (groin puncture) within 6 hours of symptom onset causative occlusion of the M2 or M3 portion of the MCAs, anterior cerebral arteries, vertebral arteries, basilar artery, or posterior cerebral arteries

AHA/ASA Guidelines Class IIB; LOE C Treatment initiated (groin puncture) beyond 6 hours of symptom onset causative occlusion of the ICA Proximal MCA M1 segment Additional randomized trial data needed

AHA/ASA Guidelines Class IIB; LOE B-R: Although benefits are uncertain Treatment initiated (groin puncture) within 6 hours of symptom onset Prestroke MRS of >1 ASPECTS < 6 NIHSS < 6 Causative occlusion: ICA or M1-MCA Additional RCT needed

Risks - complications i.v. TPA Symptomatic intracranial hemorrhage: 6.4% A potential life-threatening complication Typically occurs in the core of the infarct. sich mortality rate = 47% Serious systemic hemorrhages: ~1.6% Orolingual angioedema: 1.3% - 5.1% Endovascular mechanical thrombectomy sich 5% Emboli to new vascular territory 2% Vessel dissection 3% Vasospasm of the access vessel 3% Groin complications: 0.4-0.8% Minor: hematoma, AV fistula, pseudo-aneurysm Major: vascular death, vascular repair, vessel occlusion, or bleeding with > 3g Hb drop.

Goyal M, Demchuk AM, Menon BK, Eesa M, Rempel JL, Thornton J, et al; ESCAPE Trial Investigators. Randomized assessment of rapid endovascular treatment of ischemic stroke. N Engl J Med. 2015;372:1019 1030. doi: 10.1056/NEJMoa1414905

26 y.o. Female acute onset of weakness and difficulty speaking. Last known well 1 hour prior to admission

26 yo Female: Left Brain Stroke Before After

26 y.o. Female: Left Brain Stroke

Modified Rankin Scale 0 Symptoms 1- No clinically significant disability 2 Slight disability (patient is able to look after own affairs without assistance but is unable to carry out all previous activities 3 - Moderate disability (patient requires some help but is able to walk unassisted) 4 - Moderately severe disability (patient is unable to attend to bodily needs without assistance and unable to walk unassisted) 5 Severe disability (patient requires constant nursing care and attention) 6 - Death

Pre stroke intervention - RNs Document LSW. Document mrs pre stroke disability status (or lack thereof) NIHSS HOB flat, provided no contraindications I.v. fluids with NS (avoid hypotonic solutions) initially at maintenance or at the discretion of MD SBP < 180 but above 150 while LVO is recanalized Labs: most important for Neurointerventionalist: H&H, BUN/creatinine, PLT, PT/INR i.v. TPA if eligible. Document pedal pulses. Groin shave. Complete MRI checklist

(A) Left MCA Occlusion (B) Cerebral angiogram before (left) and after (right) mechanical thrombectomy of a proximal artery occlusion in the left MCA (C) Stent retriever

Case #43 60 y.o, h.o a-fib off A/C, mrs 0, LSW 1 hour prior to CT scan. NIHSS 19: left hemiplegia, left facial droop, left hemisensory deficit, left Neglect, right gaze preference, dysarthria

Case # 11 75 y/o female mrs 0, h/o recent left knee arthroplasty, HTN, DM, HLD, Afib, LKW 5:30 pm NIHSS 6: Left facial droop and left upper extremity drift with decreased grip strength in left hand i.v. r-tpa

NeuroIR decision making: LKW: Less than 6 hours mrs 1, NIHSS 6 ASPECT score 10 Collaterals: Excellent CTA: Right M2 occlusion

Beyond the guidelines for IAT Late presenters,6-24 hours from last seen well. Wake up strokes Patients with low NIHSS (<6) but with AIS-ELVO mrs 2-3, assessed on individual basis. Tandem occlusion (intra and extra cranial ipsilateral occlusions) Posterior circulation LVOs Providence LCOM is taking these patients. Imaging protocol may be tailored to each patient: CT/CTA/CTP vs. CT/CTA/MRI/MRP

Case #14 52 y/o male, mrs 0, HTN, DM, HLD LKW: midnight Wakes up at 7 am with left sided weakness, couldn t get out of bed EMS called Neurologist evaluated: NIHSS 7: Left lower extremity drift, left upper extremity flaccid, minor left facial droop, severe left sided sensory loss

7:18 am 7:26 am 8:15 am

Case #45 87 y.o female, mrs 3, h.o a-fib off A/C, recent ICH, on in patient rehab, LSW 9:30 am, NIHSS 33

Post endovascular therapy with or w.o i.v TPA Post procedure CT brain Transfer to ICU, HOB flat 1 st hour May raise HOB 30 degrees after an hour, provided no groin hematoma or bleeding SBP < 140-160 mmhg Nicardipine gtt NPO. i.v. fluids Neuro checks and limb checks q 15 min x 4, q 30 min x 2, q 1 hour Followup CT brain ~ 6-12 hours. Follow up MRI @ 24 hours PT/OT/ST and neurology to follow